The Rycote Practice
Thame Health Centre
Partners: Dr D Faller, Dr R Harrington, Dr K Keaney, Dr D Keeley, Dr J Makris, Dr M Vaughan
Nurse Practitioner: Mary-Anne Osborne, Ruth Tossell
NEW PATIENT APPLICATION TO JOIN THE PRACTICE LIST
Welcome to The Rycote Practice. Please complete this application form so we can trace your medical
notes and meet your health needs efficiently. You will need to bring proof of identification (eg passport,
photo driving licence) and proof of residency (eg a utility bill dated in the last 3 months) with this form.
When you have registered we will arrange an appointment with a GP or Practice Nurse for your New
Patient Health Check.
Some of the information you give us has to be shared with other people for us to treat you effectively,
manage our services and improve health and social care for the future. We only ever use or pass on
information about you if people have a genuine need to know. Wherever we can, we remove details
which identify you personally. The sharing of some types of very sensitive information is strictly
controlled by law. Please note that all staff working for the NHS have a legal duty to keep
information about you confidential.
PATIENT DETAILS:
Mr
Mrs
Ms
Miss
Date of Request:….…/.……/….…….
Other …………………… Male
Female
Date of birth:… ……/………/………
Surname:..……………………………………………….. Previous surnames:……………………………………………….
Forenames:..………………………………….. …………Preferred first name:………………………………………………
Place of birth:……………………………………………..First Language:…………………………………………………….
Ethnicity: (please tick)
White
British
Irish
Any other white
background
Black or Black British
Caribbean
African
Any other black
background
Mixed
White & Black
Caribbean
White & Black
African
White & Asian
Any other mixed
background
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian
background
Chinese
Any other ethnic
group
Other Ethnic Groups
HOME PHONE NUMBER: ……………………………. MOBILE NUMBER:…………………………………………………………
WORK NUMBER: ………………………………………. EMAIL ADDRESS:……………………………………………..................
NHS NUMBER (if known):……………………… ……………. NEXT OF KIN ……………………………………………………….
CURRENT ADDRESS:….……………….……………………………..………………………………………………………………….
……………………………………………. ………………………………… POST CODE:….………...............................................
OFFICE USE ONLY:
Photo ID seen
Proof of address seen
Staff Initials: ………………………..
Practice Manager: Karl Savage
T: 01844 261066
F: 01844 260347
E: [email protected]
W: www.therycotepractice.co.uk
The Rycote Practice
Thame Health Centre
East Street
Thame OX9 3JZ
Please help us trace your previous medical records by providing the following information:
PREVIOUS ADDRESS IN UK:…..……………………………………………………………………………………………………….
PREVIOUS DOCTOR:…………………………………………………………………………………………………………………….
SURGERY ADDRESS:………….…………………………………………………………………………………………………………
If you are from abroad:
FIRST UK ADDRESS WHERE REGISTERED WITH A GP:..…………………………………………………………………………
IF PREVIOUSLY RESIDENT IN UK, DATE OF LEAVING:..………………………………………………………………………….
DATE YOU FIRST CAME TO LIVE IN UK:………………………………………………………………………………………………
PLEASE GIVE DETAILS BELOW OF ANY OTHER REGISTERED PATIENTS LIVING AT YOUR ADDRESS?
NAME
RELATIONSHIP TO YOU
HEALTH QUESTIONS
1 Alcohol consumption – we would appreciate it if you could
complete the short questionnaire at the end of this form.
2 What is your weight?
3 What is your height?
4 Do you smoke? If you are interested in giving up smoking we offer a
stop smoking clinic at Thame Community Hospital which is free of
charge. Please telephone 01844 212727 for free and confidential
support from an experienced advisor.
Yes
Occasionally
Ex-smoker
Never smoked
5 Please give details of any allergies you have:
6 Please give details of important health problems/ illnesses or
operations you have had (please continue on the other side of this form if
necessary):
Please approx dates:
Practice Manager: Karl Savage
T: 01844 261066
F: 01844 260347
E: [email protected]
W: www.therycotepractice.co.uk
The Rycote Practice
Thame Health Centre
East Street
Thame OX9 3JZ
CURRENT REPEAT MEDICATION
Please use the space below to detail information about your current repeat medication:
HISTORY AND ADDITIONAL INFORMATION
Family Member
Year of
Birth
Year of Death
(if appropriate)
Health e.g. heart attack, angina, stroke, asthma, diabetes, cancer
Father
Mother
Number of
brothers
Number of
sisters
Number of
children
What is your marital status? Single/ Married/ Divorced/ Separated/ Widowed/ Co-habitee/ Civil Partner
Name of spouse/ partner:
Occupation of spouse/ partner:
Date of marriage:
Date of separation/ divorce:
Please give details of further education with dates:
Please list main occupations/ jobs with approximate dates:
What are your hobbies/ interests/ sport?
Are you a main carer for anyone? A carer, without being paid, provides
help and support to a friend, neighbour or relative who could not manage
otherwise because of frailty, illness or disability.
If so what is your relationship to the person you care for?
Yes
No
Friend
Neighbour
Relative
Practice Manager: Karl Savage
T: 01844 261066
F: 01844 260347
E: [email protected]
W: www.therycotepractice.co.uk
The Rycote Practice
Thame Health Centre
East Street
Thame OX9 3JZ
The following information will be sent to the Primary Care Trust to process
PATIENT DETAILS:
Mr
Mrs
Ms
Miss
Master
Other ………………… Male
Female
Date of birth:… ……/………/………
Surname:..……………………………………………….. Forenames:..………………………………….. ……….
NHS Organ Donor Registration
I would like to join the NHS Organ Donor Register as someone whose organs may be used for
transplantation after my death. (Please tick as appropriate)
Kidneys
Heart
Liver
Corneas
Lungs
Pancreas
Any of my organs
& tissue
Signature confirming consent to organ donation:……………………………………………………..
Date …………………………
It is important that you tell those closest to you about your decision to join the register as they will be
asked to confirm that you had not changed your mind.
NHS Blood Donor Registration
I would like to join the NHS Blood Donor Register as someone who may be contacted and would be
prepared to donate blood.
Have given blood in the last 3 years? YES
NO
Preferred address for donation (if different from above, e.g. place of work) ……………………………
Signature confirming consent to inclusion on the NHS Blood Donor Register:………………………
Date ……………………..
Thank you for your time to complete this application and we look forward to meeting you.
Practice Manager: Karl Savage
T: 01844 261066
F: 01844 260347
E: [email protected]
W: www.therycotepractice.co.uk
The Rycote Practice
Thame Health Centre
East Street
Thame OX9 3JZ
Name:
Date of Birth:
Male/Female
FAST ALCOHOL SCREENING TEST [FAST]
Scoring system
Questions
How often have you had 6 or more units if
female, or 8 or more if male, on a single
occasion in the last year?
0
1
Never
Less
than
monthly
2
Monthly
3
4
Weekly
Daily
or
almost
daily
Your
score
Only answer the following questions if the answer above is Less than monthly (1) or Monthly
(2). Stop here if the answer is Never (0), Weekly (3) or Daily (4).
How often during the last year have you failed to
do what was normally expected from you
because of your drinking?
How often during the last year have you been
unable to remember what happened the night
before because you had been drinking?
Has a relative or friend, doctor or other health
worker been concerned about your drinking or
suggested that you cut down?
Never
Less
than
monthly
Monthly
Weekly
Never
Less
than
monthly
Monthly
Weekly
Yes,
but not
in the
last
year
No
Daily
or
almost
daily
Daily
or
almost
daily
Yes,
during
the
last
year
Scoring:
 A score of 0 on the first question indicates FAST negative, you do not need to answer any more
questions.
 A total of 1 – 2 on the first question then continue with the next three questions.
 A total of 3 – 4 on the first question, this is a positive screen, go straight onto the
AUDIT questions overleaf
 An overall total score of 3 or above is FAST positive. Go onto ask AUDIT overleaf.
SCORE
A pint of
regular beer,
lager or cider
A pint of
“strong”/
”premium”
beer, lager or
cider
Alcopop or a
275ml bottle
of regular
lager
440ml can of
“regular”
lager or cider
440ml can of
“super
strength”
lager
250ml glass
of wine
(12%)
Bottle of wine
[12.5%]
Practice Manager: Karl Savage
T: 01844 261066
F: 01844 260347
E: [email protected]
W: www.therycotepractice.co.uk
The Rycote Practice
Thame Health Centre
East Street
Thame OX9 3JZ
Name:
Date of Birth:
Male/Female
Score from FAST (other side)
SCORE
Remaining AUDIT questions
Scoring system
Questions
0
1
2
3
4
Never
Monthly
or less
2-4
times
per
month
2-3
times
per
week
4+
times
per
week
1 -2
3-4
5-6
7-8
10+
How often during the last year have you found
that you were not able to stop drinking once you
had started?
Never
Less
than
monthly
Monthly
Weekly
How often during the last year have you needed
an alcoholic drink in the morning to get yourself
going after a heavy drinking session?
Never
Less
than
monthly
Monthly
Weekly
How often during the last year have you had a
feeling of guilt or remorse after drinking?
Never
Less
than
monthly
Monthly
Weekly
How often do you have a drink containing
alcohol?
How many units of alcohol do you drink
on a typical day when you are drinking?
Have you or somebody else been injured as a
result of your drinking?
No
Scoring:
0 – 7 Lower risk
8 – 15 Increasing risk
16 – 19 Higher risk
20+ Possible dependence
Yes,
but not
in the
last
year
Your
score
Daily
or
almost
daily
Daily
or
almost
daily
Daily
or
almost
daily
Yes,
during
the
last
year
TOTAL
Practice Manager: Karl Savage
T: 01844 261066
F: 01844 260347
E: [email protected]
W: www.therycotepractice.co.uk
The Rycote Practice
Thame Health Centre
East Street
Thame OX9 3JZ